Monthly Vaginal Douching: Is it Beneficial to Women’s Health?

Date:                     March 31, 2022

Researcher:         Dr. Martin C. Blair MD, MMSc, LLB

Institution:           Sunningdale University

Research Title:    Monthly Vaginal Douching: Is it Beneficial to Women’s Health?

ABSTRACT

Vagina douching is not a new idea. The myths, tales and home remedies riddled with erroneous false concepts of vaginal douching narrated by some: physicians, mothers, girlfriends, boyfriends, media and self-opinionated thought are all part of blatant history on women health and vaginal douching. In ancient Egypt, vaginal cleansing remedy was a mixture of wine, vinegar, and garlic. In the middle ages it was progressed to steaming the vagina with an herbal blend through a process called vaginal fumigation. This futile technique was popular among prostitutes to wash away semen and reduce disease. In the mid-19th century, French doctors promoted vaginal hygiene products as a tool for better health. In the 20th century it is promoted as the poor man’s emergency birth control. The fact is vaginal douching is the process of intravaginal cleansing with a liquid solution. Douching is used for personal hygiene or aesthetic reasons, for preventing or treating an infection (1), to cleanse after menstruation or sex, and to prevent pregnancy (2). Although there is a broad consensus that douching should be avoided during pregnancy, there is less agreement regarding douching for hygiene and relief of vaginitis symptoms. In this study I set out to answer the critical questions of: (a) What is vaginal douching (b) The purpose for vaginal douching (c) The elements of vaginal douching and (d) The impact of vaginal douching on women’s health.

STUDY METHOD

Some studies included in this review were identified via a search of the computerized MEDLINE database.

EPIDEMIOLOGY

According to past study douching products (table 1) and methods, frequency, motivation, and timing vary considerably among women who douche. The prevalence of douching has decreased since 1988, but it is still a common practice among American women, especially aged between adolescents and middle age, Afro-American women, and Hispanic women (table 2),(1, 5) and Caucasian women.  In 1995, 55 percent of non-Hispanic Black women, 33 percent of Hispanic women, and 21 percent of non-Hispanic Caucasian women reported “regular” douching (5). In the United States, there have been reports that between 50-70 percent of adolescents to middle aged woman douche at least once while another study documented 56 percent douche one or more times a week (2, 6–8). In addition, douching is not prevalent in far too many African countries, Latin America, South and Central America and in the Caribbean Islands.  Only in such country as Côte d’Ivoire, where the douching rate among women has been reported to exceed 97 percent (9). A report has also shown that it is not uncommon for women to douche daily and sporadic douching is more common (1, 8). A dose-response relation between douching and its adverse effects has been found by some, highlighting the importance of assessing douching frequency in many related research (10–14). The intensity and method of douching, especially douching with pressure, have been associated with adverse outcomes (15).

TABLE 1

Some elements and ingredients of vaginal douching products^*

^*Sources: Handbook of Nonprescription Drugs. Washington, DC: American Pharmaceutical Association and the National Professional Society of Pharmacists, 1982; and Dr. Dennis Pillion, Pharmacology Department, University of Alabama at Birmingham, personal communication, 2001.

^†EDTA, ethylenediaminetetraacetic acid; edetate, ethylenediaminetetraacetate; SD Alcohol 40, specially denatured alcohol, followed by a number or a number-letter combination that indicates how the alcohol was denatured, according to the formulary of the US Bureau of Alcohol, Tobacco, and Firearms. ^‡Medicated douches.

TABLE 2

Percentage of women who douche regularly, by age and race/ethnicity, according to the National Survey of Family Growth, United States

^*NSFG, National Survey of Family Growth.

Adverse timing and frequency in douching can have a devastating negative impact on the vagina and reproductive track of women, such as douching in relation to sexual activity. The fact is during ovulation, the levels of circulating estrogens increase, the cervical os opens, and the cervical mucus will becomes thinner (17). Therefore, the risk of pregnancy will increases and not reduced as may research claims. Some study in the past indicates that an ascending infection from the pressure of douching may be greatest around the time of ovulation when the cervical os is gaping and the mucus is thin. If the risk of ascending an infection due to the pressure of douching rather than killing the infection then it is clear that the elements, purpose and ingredients of vaginal douching has not been met.

Most women who douche consider it to be a healthy practice and often state that hygiene is their primary reason for douching. Some women state that douching is “necessary for good hygiene” (2, 6, 18). Note: women should be clear of their motives and purpose for vaginal douching before they commence, as vaginal douching must only be done to cleanse the vagina after menses and not before and after sexual intercourse so as to prevent or ameliorate an odor, to prevent or treat vaginal symptoms such as itching and discharge or pregnancy, but to prevent pelvic inflammatory diseases and other disease condition. The motivation for douching has become a complicated issue due to conflicting report and evidence. Both psychologic and social features must be formally addressed if the ambiguities and complication of vaginal douching behavior is to be modified for a better outcome.

WHAT IS VAGINAL DOUCHING­­­­

Vaginal douching is the process of intravaginal cleansing with a liquid solution that should be strong enough to kill bacterial, fungal and viral infection without adversely interfering with the normal flora of the vaginal pH so as to: (a) increase personal hygiene (b) increase the chances of pregnancy (c) to reduce and  prevent Pelvic Inflammatory Disease (PID), Ectopic Pregnancy (EP), Cervical Dysplasia (CD), Cervical Cancer (CC) Cancer of the Vagina (CV) Ovarian Diseases (OD) and for the cleansing after menstruation (1). For at least 150 years, there have been conflicting views on the benefits or harm in douching. I strongly disagree with the broad consensus that douching should be avoided during pregnancy because of (a) its relativity and basis to which such myth are presented as fact and (b) the present elements and different ingredients used for vaginal douching. To date they are less agreement regarding douching for hygiene and for the relief of vaginitis. Reviews of douching data in women from adolescents to middle age have concluded that douching is harmful and should be discouraged because of its association with pelvic inflammatory disease, ectopic pregnancy, and other conditions (4). Nonetheless, douching continues to be a common practice. Washing the vagina with soap and water is not vaginal douching and of such should not be determine as vaginal douching. Such claims also add to the many adverse outcomes that are recorded in some research.

WHAT IS THE PURPOSE FOR VAGINAL DOUCHING?

The purpose for vaginal douching should be for the achievement of maintaining good health and personal hygiene not for the protection of unwanted pregnancy and after sexual intercourse. For far too long bits and pieces of myths has surrounded and discredited the true value of vaginal douching. This is merely because of the wrong ways and approach of administration of doing things so as to achieve and fulfill an individual goal when vagina douches. Vaginal douching is not a size fits all purpose as it has been done both in the past and at present. The importance for vaginal douching in the past remains the same at present and will remain the same in the future if women are not educated on the purposes of healthy vaginal douching starting today. This can be supported by the way modern society thinks when it comes to health issues compared to the past. If modern society is to be honest with its thinking and beliefs when it comes to the concerns of the above mentioned e.g. vaginal douching for the prevention of unwanted pregnancy without increasing the negative risk factors for a negative outcome then the myths shall always overshadows the true outcomes of vaginal douching. Medicine and vaginal health can only be equal when the methods, purposes and ingredients are equally parallel to the condition as warranted.

ELEMENTS OF VAGINA DOUCHING

• Frequency
• Amount
• Duration
• Motive

FUNCTIONS OF VAGINA DOUCHING

• It must be mild but effective enough to kill or reduce bacterial, fungal and viral cells below that which may cause infection.
• It must be able to reduce unfriendly microbes that will cause harm to the lower, middle and upper reproductive track and organs.
• It must be able to kill bacteria, fungal and viral cells without significantly interfering with the normal flora of the reproductive track and pH of the vagina.

TABLE 3

Vaginal douching solution ingredient, function and amount for cleansing and protecting the reproductive tract.

Ingredients                                                       Function                                                    60ml Sol

• 1%, 5% acetic acid (vinegar)                           Acidifying                            –                   Cleansing Agent

• 1%, 5% benzoic acid,                                       Acidifying                           –                  Cleansing Agent                             lactic acid, sorbic acid                       

• 1%, 5% Povidone-iodine                                  Antimicrobial                      –                   Cleansing Agent                           5 – 10ml  Sol/before bed

• 3% or 0.5% Sodium Hypo                         Antimicrobial, Antiseptic           –                  Protect from disease

• 3%, or 0.5% Sodium Hydroxide                      Germicide                             –                  Protect from disease

• 3% or 0.5% Calcium Hypo                         Antibacterial, Antiviral              –                  Protection from disease                                                                                     Antifungal, Antiseptic           

Vaginal Douching 2.docx

Dr. Martin C. Blair MD, MMSc. LLB.

TYPES OF VAGINAL DOUCHING:

There are two types of vaginal douching that must be established from the onset.

• Vaginal Douching for Protection
• Vaginal Douching for Cleansing

Vaginal douching for protection is done so as to kill bacterial, fungal and viral cells that will harm the lower, middle, and upper reproductive tract and organs by causation of foreign intervention to the reproductive tract or organs that may cause adverse events or diseases such as Pelvic Inflammatory Disease (PID), Ovarian Disease (OD), Ectopic Pregnancy (EP), Cervical Dysplasia (CD), Cervical Cancer (CC), Cancer of the Vagina (COV), Endometritis, Salpingitis, and Peritonitis. Table 3

Vaginal douching for cleansing is done to clean the lower reproductive track and vagina area only, after menstruation. It should not be used to clean the middle and upper reproductive tract. Table 3

Vaginal douching for protection must only use to kill microbes that will harm the lower, middle and upper reproductive track.

Point to be considered before starting to vaginal douching is that vaginal douching is not a one size fits all ingredient and treatment solution because normal human anatomy is the same in everyone, medicine in the past has though us this. Although normal anatomy is the same in each and every individual, the chemistry and chemical process is different in each individual and because of such in every laboratory report there are: below normal, normal and above normal. Table 3. For vaginal pH below normal a 5% only vaginal douching solution should use for cleaning the vagina. For vaginal pH that is normal a 1% only douching solution may or may not be used for cleansing the vagina. For vaginal pH that is above normal no vaginal douching solution should be use for cleansing only solution for protecting the reproductive tract as mentioned above. In all cases for protection against diseases a 3% or 5% vaginal solution should be use regardless of vaginal pH. Vaginal douching for a condition or treatment of a diseases can be done on a frequency of seven nights on seven nights off for two months (7/7 ONx7/7 OFFx2M or until desired results) or one night on one night off for two months (1 On 1 OFF x 2M or until desired results). Monthly evaluation must be done for remission of condition or disease. According to past results from patients I have treated one month has been enough to treat the above mentioned diseases. That is reversing the condition from positive to negative.

VAGINAL DOUCHING AND ITS HEALTH EFFECT

In regards to human body cavities ranked in consecutive order from most to least hygienic are: Vagina, Anal and Mouth. Vaginal douching has been associated with far too many adverse outcomes including pelvic inflammatory disease, bacterial vaginosis, cervical cancer, low birth weight, preterm birth, human immunodeficiency virus transmission, sexually transmitted diseases, ectopic pregnancy, recurrent vulvovaginal candidiasis and infertility. However far too many study conflict and varying association among studies are contributing negatively to the fact of the healthy effect of vaginal douching. Note: I am in full disagreement with all of the above mention associated adverse outcomes from vaginal douching. There are many potentially confounding factors in the present way vaginal douching is approach that will blurred the epidemiologic assessment for a positive outcome of vaginal douching, two to be mentioned are (a) Frequency of vaginal douching and (b) Motive or purpose for vaginal douching. Vaginal douching will only be effective and healthy if the frequency of douching is done once per month every month on the day after the last day of menses. It must be done with either thought in mind (a) as a routine cleansing or (b) as a routine protection from diseases; any other reasons in mind will harbor the consequence of a negative outcome. It should be done in an alternating manner i.e. one month for routine cleansing, the next month for routine protection from reproductive tract diseases, if the true objective for vaginal douching is to be met with the least negative or adverse outcome as indicated by various report and studies. For women who are menopausal it can be done on the last day of every month or on the day of her birth with the same frequency and purposes in mind, on an alternate basis. Vaginal douching solution made for routine cleansing with (table 3, (a)) and solution made for routine protection from diseases as in (Table 3, (d), (e) and (f)) should not cause any of the adverse outcome of such as mentioned pelvic inflammatory disease, bacterial vaginosis, cervical cancer, low birth weight, preterm birth, human immunodeficiency virus transmission, sexually transmitted diseases, ectopic pregnancy, recurrent vulvovaginal candidiasis, endometritis, salpingitis, peritonitis and infertility, but the opposite to that as mention.  Douching in the United States is more common among Afro-American women (1, 5, 18). Although vaginal douching can be associated with race, poverty and those with lesser than a high school education the history of pelvic inflammatory disease and lifetime sexual partners as reported would have no effect on the elements as mentioned in (Table 3) and as such will not matter. Though one can safely attribute as a fact that, a lower educational level, poverty may lead to many sexual partners and a higher risk for sexually transmitted diseases it must also be attributed to women who perform vaginal douching secondary to infection-related symptoms rather than for routine purposes as mentioned, will be more prone to adverse outcome.

Conflicting results are reported regarding sexually transmitted infections and douching. Some studies suggest that adolescents who douche are more likely to have a history of a sexually transmitted disease (1, 15), while other studies have found that women who have a history of a sexually transmitted disease were less likely to douche (1, 10, 19). Prospective studies are needed to assess whether douching is causally related to sexually transmitted diseases or if douching is most commonly a response to symptomatic vaginitis. Whether complications like pelvic inflammatory disease might have occurred even without douching can be answered with prospective studies (1, 20, 21). As mentioned, vaginal douching must be mild to the lower, middle and upper reproductive track and organs, but effective in its response not only to the area catered to treat but also the entire body. It should not be an unhealthy process to be discouraged but one that is important and parallel to that of cleansing the oral cavity so as to prevent the oral cavity from diseases and conditions such as dental caries (tooth decay), periodontal diseases, oral cancers and oropharyngeal diseases that are largely preventable through the cleaning of the oral cavity with a toothpaste and water as stated by the Centers for Disease Control and Prevention and World Health Organization. Cleaning the oral cavity with toothpaste and water also disrupts the normal flora and pH in the mouth. Point to note here is that it is important and healthy to clean the oral cavity with a hygienic solution even though it has its own normal flora and pH to clean itself equally like the vagina. Critics must realize that it is similarly important to clean the vagina although it has its own normal flora and pH that may clean itself for a healthy reproductive tract. It must also be clear that just as the ingredients used in toothpaste to clean and protect the oral cavity, it is equally important that the ingredients used in the solution to clean and protect the vagina and reproductive tract are safe and effective.

ANATHOMY OF THE VAGINA, UTERUS, FILLOPIAN TUBES AND OVARIES 

DIAGRAM 1.0

There are several ways by which vaginal douching will contribute to a healthier reproductive tract and reduce the adverse outcome associated with it. Although it may remove normal vaginal flora, permitting the overgrowth of pathogens and provide a pressurized fluid vehicle for pathogen transport, helping lower genital tract infections ascend above the cervix into the uterus and fallopian tubes (3,) they can be avoided when it is done correctly.  To confirm it has been noted among a group of women with clinical pelvic inflammatory disease the frequent of vaginal douching was associated with endometritis and upper genital tract infection in women with normal or intermediate vaginal flora, but was not noted in women with bacterial vaginosis. An added concern should be if vaginal douching reduces the density of normal vaginal flora, bacterial vaginosis might develop or there may be a predisposition for the colonization of sexually transmitted pathogens such as Neisseria gonorrhoeae or Chlamydia trachomatous. The cause for such is attributed to the ingredients/mixture, purpose, frequency and amount of solution and duration of use. When all as mentioned are in synchrony pathogenic bacteria cannot ascend into the upper reproductive tract, leading to inflammatory scarring (endometritis, salpingitis, or peritonitis) and so as with ectopic pregnancy, early miscarriage, and infertility as the study suggest (3). Physiologic risk for sexually transmitted diseases is greater among adolescent women, since they typically have ectopic columnar epithelial cells in the exocervix with a large transformation zone that is vulnerable to bacterial and viral sexually transmitted infections (22).

MENARCH ENVIRONMENT AND ITS ECOLOGY

A healthy menarche vaginal environment is composed primarily of lactobacilli (23). Hydrogen peroxide (H₂O₂)-producing lactobacilli may protect the vagina against the overgrowth of potentially pathogenic indigenous flora and exogenous pathogens. Selected human strains of lactobacilli produce lactic acid that helps keep the vaginal pH low, usually less than 4.5, which is inhospitable to many pathogenic organisms. In addition to H₂O₂ production, lactobacilli adhere to epithelial cells, block pathogen adhesion, and stimulate the mucosal immune system (24).

Newton et al. (25) found that vaginal douching more than once per month was associated with the presence of Trichomonas vaginalis (odds ratio (OR) = 3.5, p = 0.02) and that douching one or more times a month was associated with Gardnerella vaginalis (OR = 2.4, p = 0.05). They examined Mexican-American and African-American women and concluded that race (specifically, being African American) had a more consistent association with the presence or absence of a cervical-vaginal organism than other factors, including behavioral variables. If one should consider and compare the (OR) as mentioned taking into consideration the other factors such as frequency, purpose and ingredients/elements as mentioned, it should be clear that the adverse outcome claims are bias due to incorrect or omission in their study.

It is clear that there are many different types of vaginal douching solutions that have various antimicrobial effects. Pavlova and Tao (26) used in vitro studies to show that four antiseptic douches were inhibitory against all vaginal microorganisms, including lactobacilli. Three vinegar-containing douches selectively inhibited vaginal pathogens associated with bacterial vaginosis, group B streptococcal vaginitis and candidiasis, but not lactobacilli, suggesting to the investigators that vinegar (5 percent acetic acid) douches may be less harmful or may be beneficial. Juliano et al. (27) tested seven commercial vaginal antiseptic douche solutions against vaginal lactobacilli and found marked in vitro antibacterial activity, often after very short exposure times. Thus, some douche preparations may cause substantial changes in vaginal flora. The crisis here is: are they effective as they should be if the purpose, timing and frequency are correct. See comparisons of the elements/ingredients of (Table 1) and that of (Table 3) as mentioned above.

Onderdonk et al. (28) found that healthy women who douched with a 4 percent acetic acid solution experienced a transient reduction of total bacteria that they attributed to the physical washing of the vaginal vault alone. However, when they used povidone-iodine, a bactericidal agent, it caused a significant reduction in total bacterial counts that suggested an antiseptic effect in addition to the washing effect. They concluded that, in some individuals, douching may decrease the vaginal bacteria that are present, allowing a rapid proliferation of potential pathogens, increasing the risk of associated infections. In contrast, Monif et al. (29) found that, while in vivo douching with povidone-iodine caused a dramatic decrease in the total number of vaginal bacteria, baseline counts were reestablished within 120 minutes. They also found that lactobacilli were the first bacteria to recover. As a consequence, Monif (30) has argued for the potential benefits of douching. However, these experiments do not reflect that some women may participate in a behavior that alters the vaginal ecology before it has a chance to return to normal, such as repeated douching of vagina, receptive vagina, oral or anal sex. The weight of the epidemiologic evidence suggests that repeated douching with its attendant washing and antibacterial effects will diminish lactobacilli predominance and risk reproductive tract infections.

MALODOROUS VAGINAL DISCHARGE AND DOUCHING

Bacterial vaginosis is a common cause of malodorous vaginal discharge in women (31). Three million symptomatic cases are reported annually in the United States, but millions more remain unreported or unrecognized (24, 32). A clinical diagnosis of bacterial vaginosis requires three of the following “Amsel criteria”: vaginal pH of greater than 4.5, a positive “whiff” test for amines, presence of clue cells, and a thin homogenous discharge (33).

In women with bacterial vaginosis, lactobacilli, especially H₂O₂-producing lactobacilli, are greatly decreased and the vagina becomes overgrown with anaerobic and facultatively anaerobic bacteria that are often present in small numbers in the normal vagina. These include G. vaginalis, Mycoplasma hominis, Prevotella spp., Peptostreptococcus spp., Mobiluncus spp., and Bacteroides spp. (8, 34-36). Bacterial vaginosis has been reported to be twice more common among African-American and Afro-Caribbean women than among White women (31, 37–40). Vaginal douching is also twice as common among African-American women. It has been proposed that bacterial vaginosis is sometimes sexually transmitted; however, no male factor has been identified, and bacterial vaginosis can occur in adolescent women who have never had sexual intercourse (41).

Bacterial vaginosis is common, Schwebke et al. (42) found that 78 percent of women without evidence of genital tract infection had significant, although transient, changes in their vaginal flora. Day-to-day variability was defined as less than 85 percent of a given woman’s normal vaginal flora, which was calculated on data from self-obtained vaginal smears from each woman. In a multivariable analysis, more frequent episodes of receptive oral sex were associated with unstable flora. Day-to-day variability in vaginal flora was associated with the use of vaginal medication, menses, greater number of sexual partners, spermicide use, more frequent vaginal intercourse, and less frequent use of condoms. Many of these factors are also associated epidemiologically with bacterial vaginosis and sexually transmitted diseases. It has also been reported that intrauterine device users are more likely to be diagnosed with bacterial vaginosis than are nonusers (43).

ASYMPTOMATIC, SEXUALLY TRANSMITTED DISEASES

Many sexually transmitted diseases are asymptomatic and therefore go undiagnosed, particularly in women. Two bacterial sexually transmitted diseases, gonorrhea and chlamydia are especially important causes of pelvic inflammatory disease. Chlamydia has been associated with tubal infertility due to fallopian tube scarring and obstruction (45–49), ectopic pregnancy (50) and pelvic inflammatory disease (51). In addition, both chlamydia and gonorrhea have been reported to facilitate human immunodeficiency virus transmission (22). Several studies have found an association between douching and chlamydial infection (52–54). However, cross-sectional studies cannot determine reliably whether the douching preceded the disease or if the symptoms led to the douching.

Scholes et al. (14) found that women who reported douching 12 months prior to their clinic visit were twice as likely to have cervical chlamydial infection and that, as the frequency of douching increased, the likelihood of chlamydial infection also increased. Peters et al. (52) found that douching at least monthly was significantly associated with chlamydia in adolescents. Beck-Sague et al. (53) found that, in adolescents who douched monthly or more frequently, there was a higher prevalence of chlamydia.

Foch et al. (7) found that, in adolescents attending a family planning clinic, those who reported douching were more likely to have a history of a sexually transmitted disease. Joesoef et al. (16) found that, among Indonesian pregnant women, douching with water and soap, betel leaf or a commercial agent after sex was associated with having a sexually transmitted disease and that the association was strengthened among women who douched before sex or both before and after sex. Compared with women who never douched, those who always douched with betel leaf or a commercial agent had a substantially increased risk for sexually transmitted diseases (OR = 9.4, 95 percent CI: 1.8, 50.3). Vaginal douching with irritating substances may make the vaginal mucosa more susceptible to sexually transmitted diseases, analogous to the use of intravaginal herbs as drying agents (55). Critchlow et al. found that cervical ectopy, which has been associated with acquisition of certain sexually transmitted diseases, including chlamydia and human immunodeficiency virus, was less common among women with sexually transmitted diseases who douched recently (56–59). Vaginal douching and sexual activity both may accelerate squamous metaplasia and cervical maturation (60, 61). Cervical ectopy is common in adolescents and has been associated with increased risk of sexually transmitted disease acquisition, suggesting the importance of measuring all these factors together in studies of douching and health risk. Jacobson et al.  (60) found that both douching and sexual activity may decrease ectopy in adolescents. If women who douche have less ectopy, they might eventually have a theoretically lower chance to acquire sexually transmitted diseases, although there are no data that suggest this. In contrast to the above studies, Fonck et al. (44) found that, in female sex workers in Nairobi, Kenya, there was no direct relation between douching and the risk for human immunodeficiency virus infection or other sexually transmitted infections. Similarly, Moscicki et al. (61) found no ectopy association with human immunodeficiency virus among US adolescents.

Sexually transmitted diseases and other genital tract infections have been implicated in the acquisition and transmission of human immunodeficiency virus (86–92). Vaginal flora abnormalities, including bacterial vaginosis and sexually transmitted diseases, have been found to be associated with human immunodeficiency virus infection (93–95). Normal vaginal acidity can partly inactivate human immunodeficiency virus, so if bacterial vaginosis raises the pH of vaginal fluid and recruits target inflammatory cells, women with bacterial vaginosis may be more susceptible to human immunodeficiency virus. H₂O₂-producing lactobacilli have been shown to have virocidal effects on human immunodeficiency virus type 1 (96), and a low vaginal pH may reduce the number of human immunodeficiency virus type 1 target cells in the vagina (97). Helfgott et al. (98) found significant associations between human immunodeficiency virus and bacterial vaginosis, vulvovaginal candidiasis, and trichomonas vaginitis. In a study in Côte d’Ivoire, human immunodeficiency virus was found to be two times more frequent in women using intravaginal antiseptics (9). These cross-sectional studies could be confounded in that bacterial vaginosis, sexually transmitted diseases, and human immunodeficiency virus can be the consequences of high risk sexual behavior, although several studies used logistic regression modeling to try to control for sexual behavior.

Gresenguet et al. (55), study in Bangui, Central African Republic, found that vaginal douching with non-commercial preparations was associated with an increased prevalence of human immunodeficiency virus, whereas vaginal douching with commercial antiseptic preparations was associated with a lower prevalence of this virus. However, the median years of education for women using commercial antiseptics was 8 years, compared with only 2 years for women using non-commercial preparations, so the results may be confounded by socioeconomic status.

The relation among human immunodeficiency virus, bacterial vaginosis, and sexually transmitted diseases is complex, as all may be contributed to by high risk sexual behavior. Only a few cross-sectional studies have looked at human immunodeficiency virus and douching, suggesting concern that vaginal douching might be associated with risk for human immunodeficiency virus.

POLYMICROBIAL INFECTIONS

Pelvic inflammatory disease is a polymicrobial infection primarily initiated by ascending infection to the upper reproductive tract by N. gonorrhoeae, C. trachomatis or anaerobic and/or facultative bacteria also occurring with bacterial vaginosis (62–65). It is virtually certain that the physical pressure of douching can facilitate ascension of pathogens (20). Infection, inflammation and scarring of the fallopian tubes, ovaries and/or the uterine lining can result in tubal infertility, tube ovarian abscess, endometritis, chronic pelvic pain, recurrent pelvic inflammatory disease and ectopic pregnancy. Pelvic inflammatory disease affects over 1 million American women and adolescents annually at an estimated cost of $4.2 billion in 1990 (63, 66). The total cost of pelvic inflammatory disease, including both direct and indirect costs, was projected to be more than $9 billion in 2000 (66). It was estimated that 20-30 percent of women with pelvic inflammatory disease would be hospitalized (21) and that at least 25 percent would suffer one or more serious long-term sequelae (66). Guidelines for diagnosis from the Centers for Disease Control and Prevention include complaint of abdominal pain and clinical findings of lower abdominal, cervical motion, and adnexal tenderness (67). Silent pelvic inflammatory disease that goes unreported may account for 50 percent or more of all the cases of pelvic inflammatory disease (68). About 70 percent of the women diagnosed with pelvic inflammatory disease in the United States are under 25 years of age. Risk factors for pelvic inflammatory disease have been found to include being of lower socioeconomic status, non-White, less than 25 years of age, being exposed to a sexually transmitted disease or having a history of pelvic inflammatory disease, use of an intrauterine device, failure to use contraception, multiple sexual partners, and earlier sexual initiation (69, 70).

Vaginal douching may potentially increase the risk of pelvic inflammatory disease by promoting the ascension of lower genital tract infections to the upper genital tract, by changing the vaginal environment to increase susceptibility to reproductive tract infections that precede pelvic inflammatory disease, or by introducing nonpathogenic vaginal bacteria into the typically sterile upper genital tract (21). Some study also found that there was a dose-response relation as women who douched more frequently had a higher pelvic inflammatory disease risk. In a case-control study, Wolner-Hanssen et al. (10) found that current douching was more common among women with pelvic inflammatory disease and that pelvic inflammatory disease was significantly related to frequency of douching. Neumann and DeCherney (71) found an association between pelvic inflammatory disease, vigorous and frequent (more than once a week) douching. Forrest et al. (19) reviewed the literature through 1989 and concluded that the weight of published evidence supported an association between vaginal douching and both pelvic inflammatory disease and ectopic pregnancy. Pelvic inflammatory disease is a prevalent problem worldwide, but more so in Africa and other under developed countries. Its serious reproductive outcomes and financial burdens are a major factor motivating sexually transmitted disease control and prevention. The weight of the evidence suggests strongly an association between pelvic inflammatory disease and douching. This association may represent the strongest incentive for policies to discourage women from vaginal douching.

PELVIC INFLAMMATORY DISEASE AND ECTOPIC PREGNANCY

Pelvic inflammatory disease is a common cause of reduced fertility and sterility. In an analysis of the 1995 National Survey of Family Growth, it was found that women with a history of pelvic inflammatory disease were less likely to be fecund compared with women with no such history. The likelihood of infertility increases as the number and severity of pelvic inflammatory disease episodes increase (22) and that 20 percent of women who have one episode of pelvic inflammatory disease will be infertile (72) while up to 50 percent of women who have three or more episodes of pelvic inflammatory disease will be infertile (73).

FIGURE 1

Pelvic inflammatory disease and douching. Top: This figure represents the odds ratio and 95% confidence interval from several studies that looked at pelvic inflammatory disease and douching. Bottom: This figure represents the odds ratio and 95% confidence interval from several studies that looked at pelvic inflammatory disease and various frequencies of douching. *, estimated n = 231 based on study (10).

Ectopic pregnancy is defined as implantation of a fertilized egg outside the uterine cavity (74). Women with a history of pelvic inflammatory disease were twice as likely to have had an ectopic pregnancy compared with sexually active women who had no history of pelvic inflammatory disease (22). Several studies reported that vaginal douching increased the risk for ectopic pregnancy (Figure 2). Daling et al. (77) found that there was a small increase in risk of tubal pregnancy among women who douched more than two times per year in the past year (RR = 1.3, 95 percent CI: 0.9, 1.8). This risk was found to increase further if, in addition to douching more than two times per year, the women also had more than one sexual partner during their lifetime (RR = 1.6, 95 percent CI: 1.1, 2.3) or had previous exposure to chlamydia (RR = 2.4, 95 percent CI: 0.8, 7.3). In a case-control study that controlled for chlamydial exposure, J. M. Chow et al. (50) found that current douching was an independent risk factor for ectopic pregnancy. In a different study, W. H. Chow et al. (76) reported that the risk of tubal ectopic pregnancy for women who douched at least weekly was twice that of women who never douched. In a meta-analysis, Zhang et al. (3) found that frequent douching increased risk of ectopic pregnancy by 76 percent. In a meta-analysis of case-control and cohort studies done between 1978 and 1994, Ankum et al. (75) found only a slightly increased risk for ectopic pregnancy due to douching. However, in a case-control study of ectopic pregnancy with 69 cases and 101 controls, Phillips et al. (78) found that there was not a significant increase in the risk of ectopic pregnancy due to vaginal douching once or more per month (OR = 0.8, 95 percent CI: 0.3, 2.2).

FIGURE 2

Ectopic pregnancy and douching: Top: This figure represents the odds ratio and 95% confidence interval from several studies that looked at ectopic pregnancy and douching. Bottom: This figure represents the odds ratio and 95% confidence interval from several studies that looked at ectopic pregnancy and various frequencies of douching. *, estimated n = 1,000 based on five studies (50, 75–79).

Bacterial infections of the lower and upper genital tracts can result in pelvic inflammatory disease, which can, in turn, result in reduced fertility, infertility, and ectopic pregnancy. Many studies have looked at ectopic pregnancy risk and douching, with the majority of evidence finding an association.

THE MOST COMMON CANCER IN WOMEN

Cervical cancer is among the most common cancers in women worldwide. The American Cancer Society estimates that, during 2001, about 12,900 cases of invasive cervical cancer would be diagnosed in the United States and that about 4,400 American women would die from cervical cancer (80). Cervical cancer was once one of the most common causes of cancer death for American women but now, due to early detection and treatment, it is far less so. Worldwide, cervical cancer is the second or third most common cancer among women and, in some developing countries; it is the most common women’s cancer (81). Nearly all squamous cell cervical cancer cases are related to human papillomavirus, a sexually transmitted infection. The cause of cervical cancer has been postulated to be multifactorial, with other cofactors being required. Haverkos et al. (82) proposed that tar exposure through tar-based vaginal douching products may be one such cofactor, increasing the risk of invasive cervical cancer. Cervical cancer is twice as high among Afro-American women as among White women.

A positive relation between the frequency of douching and cervical cancer risk was found in several studies (Figure 2) (3, 83–89). Graham and Schotz (83) found that, as the frequency of douching increased, so did the risk of invasive cervical cancer and carcinoma in situ. Peters et al. (84) found that the “frequency-years” of douching contributed independently and significantly to the risk of invasive cervical cancer. In a meta-analysis, Zhang et al. (3) found that douching was modestly associated with cervical cancer, when they aggregated studies that looked at both invasive cervical cancer and carcinoma in situ together or at invasive cervical cancer alone (RR = 1.25, 95 percent CI: 0.99, 1.59). However, it is unclear whether this risk ratio refers to invasive cervical cancer or both carcinoma in situ and invasive cervical cancer combined. In a population-based case-control study in Utah, Gardner et al. (87) looked at a combined study group of invasive cervical cancer (13 percent of the study group) and carcinoma in situ (87 percent of the study group) and found no association between cervical cancer and douching in women who douched once per week or less. However, in women who douched more than once a week, a positive association was found (OR = 4.7, 95 percent CI: 1.9, 11). They hypothesized that douching alters the vaginal chemical environment, making the cervix more susceptible to pathologic changes and subsequent cervical cancer.

Figure 3

Cervical cancer and douching: Top: This figure represents the odds ratio and 95% confidence interval from several studies that looked at cervical cancer and douching. Middle: This figure represents the odds ratio and 95% confidence interval from several studies that looked at cervical cancer and various frequencies of douching. Bottom: This figure represents the odds ratio and 95% confidence interval from several studies that looked at cervical cancer and long durations of douching. CIS: carcinoma in situ. ICC: invasive cervical cancer. *, estimated n = 2,081 based on six studies (83–87, 89); †, error in original paper as to lower bound of 95% confidence interval: 0.8; our estimate of likely correct lower bound: 0.3.

Although in contrast to a population-based case-control study in Costa Rica, Stone et al. (89) found that douching was not associated with carcinoma in situ or invasive cervical cancer, Herrero et al. (86), in a case-control study in Latin America, found no consistent association between vaginal douching and invasive cervical cancer and a case-control study by Brinton et al. (85) found inconsistent results related to the risk of vaginal douching and invasive cervical cancer. They found 30-40 percent non-significant elevations in invasive cervical cancer risk associated with regular vagina douching of five or more times per month, but they also found that non-regular douchers were at a higher risk than were regular douchers and that there was no clear relation to the age of first douching or total months of use. They therefore hypothesized that the association they observed may just represent chance.

Cervical cancer is a common cancer in women. Studies on cervical cancer and douching do not show a clear association, with some studies showing a positive association, some a negative association, and some no association. Although cervical cancer would not generate symptoms that might motivate a woman to douche, it is more common among women with other sexually transmitted disease and risk factors. For a definitive assessment of causality, a prospective determination would be needed, a difficult task for a chronic disease with a long latency period.

UNIVERSAL MEDICAL VIEW ON VAGINOSIS OR VAGINITIS

The near-universal medical view is that douching is not needed for routine vaginal hygiene. Monif (30) argues, however, that there is a role for douching among women with symptomatic vaginitis or vaginosis. Monif argues that douching is probably a behavioral response to an abnormal vaginal ecology, a factor not taken into account in cross-sectional studies, such that douching appears to be a cause when it is more likely to be a consequence. Monif further argues that available microbiologic data indicate douching to be harmless. Separate studies by Monif et al. (29) and by Osborne and Wright (100) suggested a positive effect of douching, as in the case of using antibacterial douches to replace systemic antibiotics during vaginally related surgery. Monif et al. (29) found that a povidone-iodine douche produced a dramatic fall in the total bacteria in the vagina for the first 10 minutes following administration. Within 2 hours, near baseline counts were reestablished, suggesting a benign nature of single episode douching.

Beaton et al. (101) found that, in women with minor vaginal irritation of unknown etiology, short-term use of a medicated povidone-iodine douche preparation resulted in improvement of symptoms, including discharge, odor, pruritus, erythema, burning, and discomfort; 94 percent of the 185 patient complaints were cleared completely. They found that 98 percent of the patients responded favorably to the douche, with no adverse effects reported. Manzardo et al. (102) found that a tetridamine vaginal lavage, twice daily for 7 days, reduced or eliminated all inflammation symptoms such as burning and leucorrhea in women with vulvovaginitis and cervicitis.

In a 1997 meeting of the Nonprescription Drug Advisory Committee of the Food and Drug Administration (103), Dr. Andrew Onderdonk presented data looking at women with abnormal vaginal ecology, such as women with culture-positive vaginal yeast infections (28). His group treated women with both sterile water, a vinegar and water douching solution, or a povidone-iodine solution. Twenty-four hours after treatment with the various douche solutions, the only women whose vaginal microflora returned to normal were the women who used the povidone-iodine douche. This suggested that, in women who have an abnormal vaginal ecology, perhaps due to a vaginal yeast infection, douching with povidone-iodine may be beneficial and may help to return the vaginal ecology back to normal values. Testing this concept in a controlled clinical trial is problematic, however, given the known risks of vaginal douching. It is unlikely that a peer review committee or a research ethics board would see merit in deliberately allocating women to a “douching encouraged” group.

Non pregnant women who are symptomatic may derive some benefit from vaginal douching, specifically with povidone-iodine, if they have abnormal vaginal ecology. However, given the many studies that has suggested adverse effects from douching compared with the very few studies that have shown a potential benefit, douching cannot be a recommended therapy and is surely not indicated for routine vaginal “hygiene.”

VIEWS ON INTRAPARTUM DOUCHING FOR ROUTINE HYGIENE

Douching has also been used in pregnant women in labor. Stray-Pedersen et al. (104) found that intrapartum vaginal douching with 0.2 percent chlorhexidine significantly reduced mother-to-child transmission of vaginal microorganisms, such as Streptococcus agalactiae and both maternal and early neonatal infectious morbidity. Dykes et al. (105) found that a single washing of the urogenital tract with 0.5 g of chlorhexidine per liter in women who were carriers of group B streptococci in weeks 38-40 of pregnancy resulted in a suppression of the number of colony-forming units of group B streptococci. However, Sweeten et al. (106) found that a one-time 0.4 percent chlorhexidine vaginal wash in laboring pregnant women did not decrease the incidence of infectious morbidity in parturients, as compared with the use of sterile water. Taha et al. (107) noted reduced maternal and newborn sepsis rates postpartum with use of an intrapartum 0.2 percent vaginal chlorhexidine wash. Neither Gaillard et al. (108) nor Biggar et al. (109) found vaginal lavage ranging from 0.2 to 0.4 percent chlorhexidine to be protective for mother-to-child human immunodeficiency virus transmission. The above studies in pregnant women look primarily at one time douching that has little to do with typical repetitive use of douching, for hygienic reasons. However, limited vaginal lavage has utility in transient reduction of pathogenic vaginal organisms’ intrapartum. Women without vaginal symptoms primarily douche for perceived hygienic or aesthetic benefit. Postcoital vaginal douching has been suggested for two purposes, reducing semen exposure to prevent pregnancy and to prevent human immunodeficiency virus transmission. After sexual intercourse, semen increases the pH of the vagina that facilitates sperm motility (99). Douching can dilute and wash out semen and can help return the vagina to its normal acidity, theoretically helping to prevent heterosexual human immunodeficiency virus transmission. Obaidullah (110) found that women who used a Betadine Vaginal Cleansing Kit before and after insertion of an intrauterine contraceptive device showed a marked absence of bacterial growth 4-6 weeks later, compared with control volunteers who used no cleansing agents. The investigators speculated that an absence of bacterial growth in the study group could help to minimize the risk of intrauterine device-related pelvic infection. These speculations and highly limited data do not, however, suggest that douching can be advocated for women. One could just as easily speculate that douching increases human immunodeficiency virus risk, increases pregnancy risk (by pressure forcing sperm into the endocervical canal, for instance), or exacerbates intrauterine device-related risks.

Despite a few dissenting views, the preponderance of the evidence suggests that douching is not necessary or beneficial and is very likely to be harmful (2–4, 6, 111–114). Multiple case reports indicate occasional very serious douching-related harm. Safran and Braverman (116) found that douching daily with polyvinylpyrrolidone-iodine for 14 days resulted in a significant increase in serum total iodine concentration and urine iodine excretion, followed by an increase in serum thyrotropin, although never above the normal range. They concluded that iodine is absorbed across the vaginal mucosa and that the subsequent increase in serum total iodine causes subtle increases in serum thyrotropin but with no overt hypothyroidism. Udoma et al. (117) reported a rectovaginal fistula following coitus in a woman in Nigeria after douching with aluminum potassium sulfate dodecahydrate (potassium alum) prior to intercourse. Vaginal douching with a bulb syringe or effervescent fluid has been reported as a cause of asymptomatic, spontaneous pneumoperitoneum (111, 118).

VIEW OF PUBLIC HEALTH ORGANIZATIONS AND VAGINAL DOUCHING

There is no official medical or public health advisory policy on whether vaginal douching should be discouraged. In January 2001, various medical organizations were contacted via e-mail and their Web sites were searched for information pertaining to vaginal douching. The following organizations replied that they have no official policy statements or positions on the use of vaginal douche products: the American College of Nurse-Midwives, the American College of Obstetricians and Gynecologists, the American Medical Association, the American Medical Women’s Association, the American Public Health Association, the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Human Development, the National Institute of Environmental Health Sciences, the National Institutes of Health, and the World Health Organization.

An American College of Obstetricians and Gynecologists’ technical bulletin (119) states that vaginitis occurs when the vaginal ecosystem is altered, which can result from several factors including repeated vaginal douching. The rationale presented in the bulletin is that repeated douching may alter the pH level or suppress growth of normal, endogenous bacteria, leading to vaginitis. A vaginitis information sheet by the American Medical Association (120) states that, in women of childbearing age, vaginitis can be caused by frequent douching. They state that women of all ages can get vaginitis from chemical irritation or an allergic reaction from vaginal douches. The Centers for Disease Control and Prevention (121) state that, in a study of African-American women, an association has been found between the length of time women douched and their risk of developing ectopic pregnancy. The Centers for Disease Control and Prevention (122) have a bacterial vaginosis fact sheet stating that women are at an increased risk for bacterial vaginosis if they douche, because douching upsets the normal balance of vaginal bacteria and that not douching can lower a woman’s risk of developing bacterial vaginosis. A Morbidity and Mortality Weekly Report article on pelvic inflammatory disease, vaginal douching was suggested as a risk factor for pelvic inflammatory disease, but the Centers for Disease Control and Prevention stated that the data (as of 1991) did not provide enough information to determine if the positive associations were due to the characteristics of the women who douche or to the vaginal douching itself (123). The Centers for Disease Control and Prevention authors found that no definitive conclusion could be reached regarding the relation between vaginal douching and pelvic inflammatory disease. Centers for Disease Control and Prevention manual on family planning in Africa cautions against vaginal douching as follows: “Douching” is unnecessary to maintain vaginal hygiene. Moreover, vaginal douching is associated with an increased risk for pelvic inflammatory disease and ectopic pregnancy. Pregnant women especially should be warned about the risks associated with vaginal douching”(124, p. 195).

The National Institute of Allergy and Infectious Diseases (125) provide a health information sheet on vaginitis that states that vaginal douching may cause vaginal irritation and vaginitis. The National Institute of Environmental Health Sciences and the National Institutes of Health both reference press releases on a study by Dr. Donna Day Baird and colleagues that found a dose-response reduction in fertility with increased vaginal douching (126). The National Institute of Allergy and Infectious Diseases (127) has a fact sheet on pelvic inflammatory disease that states that women who douche one or two times a month may be more likely to have pelvic inflammatory disease than those who douche less than once a month. Their fact sheet on sexually transmitted diseases states that, to prevent sexually transmitted diseases, sexually active women should avoid vaginal douching because vaginal douching removes some of the normal protective bacteria in the vagina and increases the risk of getting some sexually transmitted diseases (128). The fact sheet on vaginal yeast infections (vulvovaginal candidiasis) states that vaginal douching may increase the incidence of yeast infections (129). The National Women’s Health Information Center (130) has an information sheet specifically on vaginal douching, stating that douching makes women more susceptible to bacterial infections and spreads existing infections into the upper reproductive tract. The National Women’s Health Information Center claims that women who douche have increased bacterial vaginosis, sexually transmitted diseases, and pelvic inflammatory disease; that vaginal douching does not prevent pregnancy but may decrease fertility; and that vaginal douching increases the risk of low birth weight babies and ectopic pregnancy. They also state that the safest way to clean the vagina is to let the vagina clean itself, which it does by secreting mucus. Their final recommendation was that, if a woman has vaginal discharge, she should seek medical attention without first douching because washing away the discharge makes it harder to identify the infection.

On April 15, 1997, the Nonprescription Drug Advisory Committee of the Food and Drug Administration held a meeting to discuss vaginal douching (103). Presentations was from the Food and Drug Administration, the Nonprescription Drug Manufacturers Association, and the Purdue Frederick Company (manufacturer of Betadine medicated douche), among others. The Committee concluded that there was not enough information to determine that a causal relation existed between douching and its adverse outcomes. More research was recommended and the Food and Drug Administration was urged to look into federal regulation and better product labels. The Committee found that some of the studies had residual confounding due to sexual behavior and underreporting of sexually transmitted diseases. A key point in the argument was that, without determining a temporal relation, the studies so far have not been able to tell which came first, vaginal douching or the adverse outcome (sexually transmitted diseases, pelvic inflammatory disease, infection), when douching may be undertaken as a way to treat the symptoms of the disease

IS VAGINAL DOUCHING NECESSSARY

Yes, vaginal douching is necessary for routine cleansing of the lower reproductive track and for protection of the lower, middle and upper reproductive tract and organ from diseases and the spread or development of an infection if done correctly. As set out above, the concern should not be that of altering the balance of normal bacteria that are present in the vagina, as discussed previously. If and when done correctly the risk will not be that of a decreased in personal hygiene, but an increase in personal hygiene or a decrease in the chance of pregnancy, but an increase in the chances of pregnancy. It will reduce and can prevent Pelvic Inflammatory Disease (PID), Ectopic Pregnancy (EP), Cervical Dysplasia (CD), Cervical Cancer (CC), Cancer of the Vagina (CV) and Ovarian Diseases (OD) and not increase any of the aforementioned. Vaginal douching should not be used to prevent the chances of getting pregnant. It should be used for the cleansing after menstruation (1) if used correctly it should not increase the chances for infection caused by bacterial vaginosis and vaginitis, sexually-transmitted diseases, pelvic inflammatory disease. It may cause some vaginal irritation in some women when the ingredient used in vaginal douching solution is too strong for the individual. As mentioned elsewhere in this report that “Vaginal Douching Solution” is not a one size fits all solution, it’s a fact that cannot be disputed. Likewise it is also a fact that “vagina douching solution” can disrupt the balance of the normal flora in the vagina by alteration of the vaginal pH and any negative or positive changes from the normal pH in its composition can lead to an increased risk of vaginal infections such as fungal infections, bacterial infection or viral infection. Douching can also cause the spread of harmful bacteria further up into the reproductive tract if an infection is already present in the vagina, but can it be called vaginal douching for cleansing purpose or vaginal douching for protection against diseases if the ingredients used in a vaginal douche in susceptible to the bacteria, fungus or virus in the reproductive tract so as to cause harm to the women body. The argument proposed is if the bacteria, fungus or virus are located in the middle reproductive tract, the pressure from douching may push it further into the upper reproductive tract which should not be the argument because in this case if the purpose for vaginal douching has been met as stated above and elsewhere all bacteria, fungus and virus will be killed immediately before causing any harm or infection. Again this is why as they should be two types of vaginal douching, one for cleansing and one for protection that should be done on an alternate basis monthly.

DETERMINATION, FUTURE DIRECTIONS AND CONCLUSIONS

The current events and findings suggests that future studies must directly assesses the extent to which vaginal douching is a causal factor and not a myth that diseases such as pelvic inflammatory disease, bacterial vaginitis, bacterial vaginosis and other sexually transmitted diseases cannot be caused by behavior that is common among women who are at risk of sexually transmitted diseases but is caused by vaginal douching due to symptomatic response. My personal take is that perhaps the adverse effect associated with vaginal douching is embedded in the preceded sentence. Although an American College of Obstetricians and Gynecologists’ technical bulletin states that vaginitis occurs when the vaginal ecosystem is altered, it can also result from several factors including repeated vaginal douching. In this case it’s not clear what repeated vaginal douching meant as it mentioned no frequency and other key factors as mentioned elsewhere above and below in this article. The rationale that is also presented in the bulletin is that repeated douching may alter the pH level or suppress growth of normal endogenous bacteria, leading to vaginitis. The American Medical Association also states that vaginitis in women of childbearing age can be caused by frequent douching. Here again the question is how to determine frequent douching. They also state that women of all ages can get vaginitis from chemical irritation or an allergic reaction from the ingredients used in vaginal douche. The Centers for Disease Control and Prevention state that, in a study of African-American women, an association has been found between the length of time women douched and their risk of developing ectopic pregnancy. They also have a bacterial vaginosis fact sheet stating that women are at an increased risk for bacterial vaginosis if they douche, because douching upsets the normal balance of vaginal bacteria while at the same time mentioned that not douching can lower a woman’s risk of developing bacterial vaginosis. In the Morbidity and Mortality Weekly Report article on pelvic inflammatory disease, vaginal douching was suggested as a risk factor for pelvic inflammatory disease, but the Centers for Disease Control and Prevention stated that the data (as of 1991) did not provide enough information to determine if the positive associations were due to the characteristics of the women who douche or to the vaginal douching itself this is also conflicting to other statement or writing they provided about vaginal douching. It can also be found in writing elsewhere that the authors for The Centers for Disease Control and Prevention found that no definitive conclusion could be reached regarding the relation between vaginal douching and pelvic inflammatory disease. While at the same time The Centers for Disease Control and Prevention manual on family planning in Africa cautions against vaginal douching as follows: “Douching” is unnecessary to maintain vaginal hygiene. Moreover, vaginal douching is associated with an increased risk for pelvic inflammatory disease and ectopic pregnancy. Pregnant women especially should be warned about the risks associated with vaginal douching. The National Institute of Allergy and Infectious Diseases has a fact sheet on pelvic inflammatory disease that states that women who douche one or two times a month may be more likely to have pelvic inflammatory disease than those who douche less than once a month. Their fact sheet on sexually transmitted diseases states that, to prevent sexually transmitted diseases, sexually active women should avoid vaginal douching because vaginal douching removes some of the normal protective bacteria in the vagina and increases the risk of getting some sexually transmitted diseases.

The evidence as provided in Table 1 suggests that stronger regulations for vaginal douche products should be indicated, including ingredient control, clearer labeling, and a required statement on product advertisements and on the products themselves. No prospective cohort study or a randomized clinical trial, or randomized community trial, assigned at random to treatment, no treatment can address the questions of ambiguity surrounding vaginal douching and its benefits towards women health without first addressing the lagging information gap of knowledge and education on vaginal douching. Only an educational program regarding the potential dangers associated with adverse vaginal douching in women who douche will make that change for a better informed consent in douching. The lack of knowledge and the preponderance of ignorance is the key elements that are hindering the true benefits of vaginal douching.

Women who douche for hygienic reasons must be informed with the present knowledge that routine douching on a once a monthly frequency can maintain vaginal hygiene when followed accordingly. As stated in this article I believe that the responsibility to ensure that the policy for vaginal douching rest squarely on the shoulders of the government and professional health organizations for the safety of women health, so that the benefits can be received by each and every individual women who vagina douche.

However, given the many studies that has suggested adverse effects from douching compared with the very few studies that have shown a potential benefit, douching cannot be a recommended therapy and is surely not be an indication for routine vaginal hygiene. The problem here is it is not the responsibility of the researcher or flaws in such study, but the information of the minds of those who vagina douches. The World Health Organization (WHO) and other women health organization around the world must embark upon fulfilling that gap of making the difference through knowledge and education.

My observation on many of the research sited is that (a) the approach taken and observation sited on vaginal douching in women has lacked the vital elements, frequency, purpose, ingredients and motive in those women who vaginal douche and because of those omission more harm than good has been inflicted on women health, (b) the lagging information gap demonstrated by most women douchers is the foundation for the outcome of such negative results. There should only be one frequency and one of two motives to vaginal douching. It is either to clean the lower reproductive track from possible infections or to protect the lower, middle and upper reproductive track from possible diseases and infections. Looking at the adverse outcome of the negatives, positives, mixed and conflictive reports written on vaginal douching among women who douches and women who abstain from douching for whatever causes, it is clear that the problem is not the research or the way the research was performed, or the biasness of two conflicting research. It is clear that there are two problems or issues to be solved (a) because of the differences in aims and motives propounding in the minds of women and the purposes for vaginal douching, adverse outcome in women who vaginal douche will remain parallel to the negativity of its outcome and (b) women education on the effects of different solutions, type of solution, element, ingredients, purpose, methods, frequency, motivation and timing vaginal douching is important because it can have an adverse on their body. It must be foremost considered as the main factors that can hinder the true outcome on vaginal douching. If we are to see the health benefits for vaginal douching among women vaginal douchers, then we must start by educating the women of does and don’t, if we are to change the world from its negative perceptions’ on vaginal douching.

My final conclusion is given the vast pool of women infected worldwide with human immunodeficiency virus, other sexually transmitted diseases, bacterial vaginosis and the increased risk attributable to vaginal douching; to discourage vaginal douching by women may have a huge impact on the risks of an increase of infections and reproductive health consequences for women. There are far too many negatives against vaginal douching that are not supportive to the claims and conclusion of the negative health benefits, than positive health benefits for vaginal douching for which the real hidden attribution may be the cost for vaginal douching.

ACKNOWLEDGMENTS

This work was supported by Sunningdale University in Lusaka Sunningdale University Research Center, Dr. Martin C. Blair MD, MMSc., (Principal Investigator).

Correspondence to Dr. Martin C. Blair MD, MMSc, LLB, (e-mail: martinblair1958@gmail.com)

FIGURE 1

Pelvic inflammatory disease and douching. Top: This figure represents the odds ratio and 95% confidence interval from several studies that looked at pelvic inflammatory disease and douching. Bottom: This figure represents the odds ratio and 95% confidence interval from several studies that looked at pelvic inflammatory disease and various frequencies of douching. *, estimated n = 231 based on study (10).

FIGURE 2

Ectopic pregnancy and douching. Top: This figure represents the odds ratio and 95% confidence interval from several studies that looked at ectopic pregnancy and douching. Bottom: This figure represents the odds ratio and 95% confidence interval from several studies that looked at ectopic pregnancy and various frequencies of douching. *, estimated n = 1,000 based on five studies (50, 75–79).

FIGURE 3

Cervical cancer and douching. Top: This figure represents the odds ratio and 95% confidence interval from several studies that looked at cervical cancer and douching. Middle: This figure represents the odds ratio and 95% confidence interval from several studies that looked at cervical cancer and various frequencies of douching. Bottom: This figure represents the odds ratio and 95% confidence interval from several studies that looked at cervical cancer and long durations of douching. CIS, carcinoma in situ; ICC, invasive cervical cancer *, estimated n = 2,081 based on six studies (82–86, 88); †, error in original paper as to lower bound of 95% confidence interval: 0.8; our estimate of likely correct lower bound: 0.3.

TABLE 1

Some vaginal douching products*

* Sources: Handbook of Nonprescription Drugs. Washington,

DC: AmericanPharmaceutical Association and the National Professional Society of Pharmacists,1982;

† EDTA, ethylenediaminetetraacetic acid; edetate, ethylenediaminetetraacetate; SD Alcohol 40, specially denatured alcohol, followed by a number or a number-letter combination that indicates how the alcohol was denatured, according to the formulary of the United States Bureau of Alcohol, Tobacco, and Firearms.‡ Medicated douches.

TABLE 2

Percentage of women who douche regularly, by age and race/ethnicity, according to the National Survey of Family Growth, United States.

* NSFG, National Survey of Family Growth.

Abbreviations

COV        Cancer of the Vagina

CIS          Carcinoma in Situ

CC           Cervical Cancer

CD           Cervical Dysplasia

CI            Confidence Interval

EP           Ectopic Pregnancy

ICC          Invasive Cervical Cancer

OCD        Ovarian Cancer Diseases

OR           Odds Ratio

PID         Pelvic Inflammatory Disease

RR           Relative Risk